When the edits were put into place Oct. 30, 2000, HCFA stipulated that an E/M service would be payable on the same day as the bundled procedures only if it was significant and separately identifiable. Coders were required to append the E/M service with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when submitting the claim.
HCFA has provided no reason for the suspension. However, coding experts believe the agency is responding to physicians and coders who have reported a big increase in denials when they bill E/M services with diagnostic tests like x-rays, spirometry, EKGs and cardiac event monitoring, even when modifier -25 is attached. HCFA has not closed the door on reintroducing the suspended edits, but has made clear its intentions to educate physicians and carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service.
Edits Were Intended to Prevent Double-dipping
HCFAs apparent determination to pay only for E/M services deemed significant and separate is due, at least in part, to chronic double-dipping by some physicians when diagnostic tests are performed, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. In fact, when it introduced the edits, HCFA stated they were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.
Although HCFA now says that any denied claims involving E/M services and diagnostic tests submitted after Oct. 30 should be resubmitted, it recommends that physicians continue to attach modifier -25 to the E/M service when refiling the claim. In other words, family physicians must demonstrate in the patients medical record that the E/M service was significant and separately identifiable. Presumably, any new E/M services performed with a variety of diagnostic tests and other services with no global days also require modifier -25.
Reporting E/M Services With Modifier -25 Correctly
Family practices may report an E/M service (modified by -25) and expect payment if documentation indicates the visit led to the decision to perform the procedure, according to Christine Schon, FACMPE, senior director of physician [...]